System Safety and Risk Management.ppt

7/27/2019 System Safety and Risk Management.ppt

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Presented by AFS-900Sunday, October 06, 2013

System Safety and Risk Management

Amer M. Younossi


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Modules1 Why Flight Standards Is Implementing


2 Risk Concepts3 System and Organizational Principles

4 Human Factors

5 Data and Analysis

6 Risk Management

Module 1 Module 2 Module 3 Module 4 Module 5 Module 6

Outline How Why Objectives/Functions Authority Challenges Summary


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Module 1 Outline How did we get here?

Why do system safety?

AFS-900 objectives and functions

Where is our authority?

System safety challenges

Summary


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How Did The FAA Get Here?

90-Day Safety Review White house and congressional

mandates to reduce the

accident rate by 80% in 10

years




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90-Day Safety Review The task force categorized issues into six general areas:

certification policy and process

resource targeting to address safety risks

newly certificated air carrier operations and growth

outsourcing and varied fleet mix

inspector and air carrier guidance material

inspector resources




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Policy Statement of the FAA Aggressive attitude with respect to aviation safety

Pro-active approach

Air carrier to maintain the highest possible degree of

safety

Achieve this in the most economical and efficient

manner to the government and the carrier

Source: FAA Order 1000.1A




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FAA Mission Statement Setting regulations and standards for:

air carriers

air commerce

air agencies

airmen, etc.

Accomplishing certification, surveillance, inspection,

investigation and enforcement activities

Managing the systems for registry of ...

aircraft

airmen


Flight Standards VisionTo be recognized and respected world-

wide as the foremost authority on system

safety approaches for regulation and

certification



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Why Do System Safety Air traffic is increasing

Aviation operations are becoming more complex

FAA oversight staff and resources are constrained

We can no longer afford to function as

a direct source of QC

Systems approach is proactive -

Stresses process improvements

System safety is good business




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System Safety Defined

The application of special technical and managerial skillsin a systematic, forward-looking manner to identify and

control hazards throughout the life cycle of a project,

program, or activity.

Source: System Safety Course, FAA Academy




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System Safety Philosophy System safety is:

Validation of regulatory compliance

Review and validation of systems and entire programs,

not portions

Application of safety attributes

Application of risk management




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AFS-900 Objectives

Air carrier certificates are our gold standard tomeasure how well we are accomplishing our

responsibilities.Dave Gilliom ~ AFS-900

Standardize air carrier certification

Standardize systems and targeting risks

Centralize information management functions

Six Processes are ISO-9000 Certified




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ATOS Model


Policy------------------------------------------------

--------

Module 1

SystemConfiguration

Module 2Certificate

Management

Module 3Surveillance

Resource Mgmt


Module 5Reporting

Module 6EvaluationModule 7

Analysis

Module 8Implementation

Module 1

SystemConfiguration

Module 2Certificate

Management


Resource Mgmt


Module 5Reporting

Module 6EvaluationModule 7

Analysis

Module 8Implementation



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AFS-900 Functions Certification, Standardization, and Evaluation Team (CSET)

Certification

Surveillance/Evaluation Planning

Aircraft conformity team

Technical support program

Air Transportation Oversight System (ATOS) Improve the certification and surveillance processes for air carriers

Ensure regulatory compliance and incorporate a systems approach

Enhance the surveillance process Standardize the surveillance processes

Flight Standards Safety Analysis Information Center (FSAIC)

Provide analytical support to Flight Standards

Identify industry-wide risk areas

Partnership with aviation safety research institutions




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AFS-800 Function Improve the oversight process for general aviation

Open communications with air operators.

Identify focus areas to target, and provide feedback to

operators.


System Safety Approach for General Aviation (SAGA)



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Integrated System Safety Efforts

Business process procedures, guidelines, andautomation tools

Data quality enhancement and database

standardization

Risk management/analysis procedures and automation

Interconnectivity of agency and industry databases


SASO~ Systems Approach for Safety Oversight



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Where Is Our Authority? Title 49 44701, 44702

Current 121 Rules




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USC Title 49Sec. 44702. Issuance of certificates

...

(B) considerations. - When issuing a certificate under this

chapter, the adminis t rator sh all-

(1) consider-

(a) the dutyof an air carrier to provide service with

the high est pos sible degree of safetyin the

public interest.

...




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USC Title 49Sec. 44701. General

requirements

(A) prom ot ing safety. -

The adminis t rator of

the FAA shal lpromote

safe flight of civil aircraft

in air commerce by

prescribing -

...

(2) regulations and

min im um standardsin

the interest of safety




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14 CFR Part 121 Rules14 CFR part 121.135 (a) (1)

each manual required by

121.133 mus t-

(1) include instructions andinformation necessary to

allow the personnel

concerned to perform their

duties and responsibilities

with a high degree of

safety;

...




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System Safety Challenges Operators organizational structures

Systemic orientation and completeness of regulations

Defining and measuring safety

FAA and industry cultures

Human factors

Availability of valid, reliable data that are

representative of the system

Risk management application




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Summary

90 day safety review

System Safety

AFS-900




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Module 2Risk Concepts


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Module 2 Outline Fundamentals of Risk

Definitions of Risk

Common Concepts of Risks

Risk Factors/Controls

System Safety

Summary

Outline Fundamentals Definitions Concepts Risk Factors System Safety Summary

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Risk Management Risk management is a core process to system safety.

Risk management can be practiced at all levels and in all

types of aviation.

Safety is not equivalent to risk free

U.S. Supreme Court, 1972

Risk management is a more realistic term than safety

Jerome Lederer, 1928




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Basic Risk Concepts Event

Accident, Incident, Occurrence

Undesired event resulting in loss

Hazard

Condition that can cause event

Risk

Likelihood / severity of event associated with the hazard

Exposure to hazard...

Likelihood of occurrence

Severity of consequences




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Schools of Thought Product Development (Traditional SS)

Organizational Psych (e.g. James Reason)

Project Management (Risk Management e.g. SEI)

AFS approach is a blend




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Definition(s) of Risk Several definitions exist, based upon the context for

which they were developed

More than one are used in AFS programs

All have a common underlying set of concepts




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281 Source: Product school

Common Concepts What is it that I will run into, hit, trip on, etc.?

Hazard, condition, failure, threat

Something bad can happen to us

Undesired event, mishap, consequence

How likely is it to happen?

Likelihood, probability (impact)1

How bad will it hurt if it does? Severity, impact (impact)1




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AFS Accepted Definition

Safety risk is an expression of the impact of an undesiredevent in terms of event severity and event likelihood.

Source: FAA Order 8040.4, Safety Risk Management - Product School




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Risk Factors and Control Most system risk is incurred through factors involving

severity or likelihood

Most deal with factors increasing likelihood of ahazardous condition

Risk controls typically:

Help detect likelihood-increasing factors

Lower the likelihood

Eliminate the hazard




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Risk FactorsThings about the inherent hazard, system design, or

organizational performance that affect risk likelihood or

severity.

Task complexity

Environmental factors

Difficult procedures

Poor or missing supervisory controls

Poor Communications




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Risk Controls (Mitigation) Serve to reduce likelihood or severity

Be wary of substitution risk

Controls must recognize human factors and culture




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Risk Involving Organizations Inherent risk

Cause of the problem

Design deficiencies Failure provide controls on the problem

Performance Deficiency

Failure to comply with design

failure to the design to control risk




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Inherent Hazards and Risk?

Operation

Hazard

Environment




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System Design and Risk

Procedures

Interfaces

Resources

Process Controls

Process Measures

System




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System Performance Conformance/compliance

Are we complying with the design of the system?

Effectiveness Does the system accomplish its intended function (control

the risk factors)?




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Regulations as Risk Controls Based upon public law (49 USC 447)

Regulations and approved programs may be risk

controls.

Effectiveness is bounded by specificity of regulations,

programs, manuals, etc.

Proper application is essential!




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System Safety Model The FAA will use the System Safety Process Model as a

basis.

Model was adapted from Nicholas J. Bahrby AFS-900and ASY-300 for use by Flight Standards




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System Safety Process


Modify

System/Process

System/Process Review

Define Objectives

Validation of Control:

Results for Further Action

System Descriptions

Hazard Identification:

Identify Hazards & Consequences

Risk Analysis:

Analyze Hazards & Identify Risks

Risk Assessment:

Consolidate & Prioritize Risks

Decision Making:

Develop an Action Plan

Risk Management

Documentation



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System Safety Process1 - Identify the task(s)/functions

2 - Describe the environment

3 - Identify the hazards

4 - Evaluate the risk ...




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System Safety Process5 - Identify and evaluate mitigating strategies

6 - Decide on a course of action

7 - Evaluate effectiveness of controls




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Risk PerceptionsCarelessness and

overconfidence are more

dangerous than deliberately

accepted risk

- Wilbur Wright, 1901

Wilbur Wright gliding, 1901

Photographs: Library of Congress




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Summary




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Module 3System and

Organizational

Principles


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Module 3 Outline What is a system?

Tasks, functions and environments

System attributes

Operator's Objectives

Regulators Objectives

Summary


Outline System Attributes Operator Objectives Regulators Objectives Summary
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System and Organizational Principles

Accidents Are Not Due to Lack of Knowledge, but Failure

to Use the Knowledge We Have.

- Trevor Kletz, What Went Wrong?

July 17, 1996

8:31:10 PMTWA Flight 800

Boeing 747-131, N93119

153rd aircraft built (1971)




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A system is a composite of people, tools, procedures,

materials, equipment, facilities, and software operating in a

specific environment to perform a specific task or achieve aspecific purpose, support, or mission requirement.

- Roland and Moriarty, System Safety Engineering and Management

A system is a composite ofpeople, tools,procedures,

materials, equipment, facilities, andsoftware operating in a

specific environment to perform a specific task or achieve aspecific purpose, support, or mission requirement.

- Roland and Moriarty, System Safety Engineering and Management

Whats a System?

Systems

PeopleToolsProcedures

Materials

EquipmentFacilities

Software...a set of components

that act together as a wholeto achieve a common goal




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Situation - EnvironmentWhat Are the Conditions?

Physical environment

Facilities

Airports

Weather patterns

Operational environment

Type of operation Type of equipment

Employee demographics

Financial factors




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Situation - Tasks and FunctionsWhat Is Being Done?

Tasks - accomplished by humans

Pilot tasks - Advanced Qualification Program (AQP) Maintenance tasks - Work cards

Functions - organizational structures to accomplish tasks




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Authority

Controls

Responsibility

Procedures

Interfaces

Process

Measurement

System SafetyAttributes

System Safety Attributes




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What is a Process?A Process is a set of tasks, work-flows and information flows thatproduce a desired result.

Source: System Safety Course, FAA Academy

If you can't describe what you are doing as a process, you don't knowwhat you're doing.

W. Edward DemingUS business advisor & author

(1900 - 1993)


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Resources

Controls

System Based Process



Inputs Process Outputs